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WVL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name He3�ne Irl WELL AND BORING RECORD � 6 Q <br /> Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n <br /> I <br /> V. v. u <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> El Cable Tool p Driven C1 Dug <br /> I t: �'f Il}C<i�v Road Orono, M�t. ❑ Auger f�-Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID <br /> N ; <br /> USE El Monitoring [IHeating/Cooling <br /> C Domestic ❑ CommunityPWS <br /> ❑ Industry/Commercial <br /> -�- - - - - -�- ❑ Irrigation 71 Noncommunity PWS ❑ Remedial <br /> W E T ,..�- ❑ Test Well <br /> 11 Dewatering ❑ <br /> -r -7- -r- -r <br /> CASING Drive Shoe? ❑ Yes ❑ No HOLE DAM. <br /> :: ❑ Steel ❑ Threaded ❑ Welded <br /> I;k,Plastic ❑ <br /> s <br /> 1 Mile <br /> CASING DIAMETER WEIG T <br /> PROPERTY OWNER'S NAME " 117 1 'ci 7 7/8 3 f § <br /> Ke1 �1Waters & Tia C1Cl r _i into ft. lbs./ft. qi P <br /> in.to ft. lbs./ft. - in.'to Z—1 1 <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> 10340 VikingDr]_i E' Make C3 t33SC`11 from to A. <br /> .SSE. 1 3 0 Type ,t:ainle-`ss bt ep I Diam. <br /> t5 '[�C Slot/Gauze <br /> Eden Prairie, MN. �.,� x Length_ <br /> Set between ft.and ft. FITTINGS: = X 3 t° tl xi.` <br /> STATIC WATjR LEVEL <br /> WELL OWNER'S NAME b G ft. E*,below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. 1 1 ft. after hrs.pumping 3 t, 1 T g.p.m. <br /> WELL HEAD COMPLETION <br /> 41 Pitless adapter manufacturer Wh 1 t'_wa{`.ca TModel <br /> ❑ Casing Protection 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ❑aYes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete Ct.,HI h Solids Bentonite <br /> MATERIAL FROM TO <br /> GEOLOGICAL MATERIALS COLOR g <br /> from o to 3 Ift. ❑ yds.t9 bags <br /> from to ft. ❑ yds. ❑ bags <br /> 1./ ) Brown _; S' t from to ft. ❑ yds. ❑ bags <br /> NEARESTXNOWN SOURCE OF CONTAMINATION ^ F <br /> t9--, , feet i direction type <br /> [X Yes�•Z } � �f .a�) Well disinfected upon completion? IYes ElNo /! L <br /> W,-!ter Sand Grey S 1 9 J 1 12;L�; 1 PUMP <br /> ❑ Not installed Date installed 1 _`J-3 / <br /> Manufacturer's name = <br /> Model number l.; t HP '2 Volts 1 <br /> Length of drop pipe 64 } ft. Capacity 1 8 — <br /> 9-p.m-Pressure Tank Capacity $')r, C: r <br /> Type: F'-Submersible ❑ L.S.Turbine O Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes X No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes f�No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,it needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> DON STODOLA WELL DRILLING CO. , INC. <br /> Licensee Busmes ame -Lic.or Reg.No. --7172 <br /> Aut orized Representative Signature pate. <br /> CIhuc.,k Moore i �L _ -1fi <br /> 5 8 8 4 6 Name of Driller Date <br /> HE-01205-05(Rev.1/95) <br />